LAUSR

Endoscopic ultrasound (EUS)-guided biliary drainage is an alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with malignant biliary obstructions and those for whom endoscopic retrograde cholangiopancreatography (ERCP) fails or is impossible. Duodenal stenosis attributable to tumor overgrowth is a classic example of the latter situation. Although increasing evidence indicates that EUS-guided biliary drainage is superior to PTBD [1], only a few expert centers routinely perform the former procedure, which is technically challenging. Recently, new lumen-apposing metal stents (LAMS) placed via electrocautery have become available; these can be used to aid EUS-guided choledochoduodenostomy (EUS-CDS). These all-in-one devices facilitate fast, safe EUS-CDS without the need for device exchange [2]. Here, we report the case of a 60-year-old man with duodenal and biliary obstructions secondary to pancreatic head cancer (▶Fig. 1 a). The dilated bile duct was easily visualized close to the duodenal bulb using an endoscope placed via the conventional long route (▶Fig. 1b). After direct puncture of the bile duct using the electrocautery device (AXIOS System; Boston Scientific, Marlborough, Massachusetts, USA), the sheath was pushed toward the opposite wall of the bile duct for correct positioning of the LAMS (6mm diameter) (▶Fig. 1 c). After locking the sheath, the distal flange was opened under EUS guidance E-Videos